Clinical Documentation Improvement (CDI) Review Practice Questions 2024.

Clinical Documentation Improvement (CDI) Review Practice Questions 2024. Clinical Documentation Improvement (CDI) - correct answer Process an organization undertakes that will improve clinical specificity خصوصية and documentation that will allow coders to assign more concise disease classification codes. The data quality attributes essential to CDI - correct answer 1.Precision دقة 2. Comprehensiveness. 3. Consistency تماسك 4. Accuracy دقة 5. Timeliness Precision دقة - correct answer documentation supports the purpose of the health record Comprehensiveness: - correct answer complete with maximum content, including the importance data having an impact on decisions made for patient treatment / care. Consistency تماسك - correct answer documentation is reliable and has the same information in all parts of the health records Accuracy دقة - correct answer documentation is free of any identifiable errors Timeliness: - correct answer documentation is up-to-date What may result from improved clinical documentation? - correct answer 1. Reduced risk associated with healthcare compliance. 2. Minimized vulnerability to external audits, such as the Recovery Audit Contractors. 3. Identify areas that may indicate quality of care issues. 4. Improve reporting for quality measures, present of admission indicator, pay for performance programs, value-based purchasing, data used for decision-making in reimbursement methodologies, and better information for reporting the patient care provided. The core designated clinical documentation set for coding compliance in the acute care inpatient health record: - correct answer 1. Attending physician documentation. 2. Other provider documentation. 3. Diagnostic test results, Pathology reports Attending physician documentation: - correct answer H&P, problem list, progress notes, orders, operative reports, discharge summary.